I (Client) *

First Name

Last Name

This release is active until:

MM

DD

YYYY

Regarding Recovered Memories and Legal Rights: *

Research has found that memories uncovered during hypnosis, or other forms of induced altered state, may not be accurate or even factual. Memory is a constructive and reconstructive process. What is remembered about an event is shaped by what was observed, by conditions prevailing during attempts to remember, and by events occurring between observation and the attempted remembering. Memories can be altered, deleted, and created by events that occur during and after the time of encoding, during the period of memory storage, and during attempts at retrieval. Memories that occur either spontaneously or following the use of special procedures in therapy may be accurate, inaccurate, fabricated, or a fixture of these. This suggests that any memory uncovered during a hypnosis session be considered as a possible construct of mental process, and not necessarily an actual event. Therefore, in the event that during the course of hypnotherapy, memories should surface that may be considered grounds for future litigation, you may lose your legal right to use this information in a court of law, as it would not be admissible. If it should occur that certain types of memories begin to surface during the session with an HCH Hypnotherapy Intern under Holly Holmes-Meredith’s supervision, the session will be discussed so that you may decide whether or not to proceed further with the hypnosis, based on your understanding and careful consideration of the above information.

I have read the above and agree to participate in hypnotherapy.

Name *

First Name

Last Name

My Son/Daughter *

First Name

Last Name

Parent/Legal Guardian *

First Name

Last Name

Date *

MM

DD

YYYY

I (Parent or Guardian) *

First Name

Last Name

Release written information or records on my daughter/son: *

First Name

Last Name

In addition, I give permission for information to be exchanged verbally between the above mentioned parties. This release is active until :

MM

DD

YYYY

Please check: *

Permission Granted